Psychologists Frederick Thorne and Peter Nathan (1969) reviewed studies that had compared patients’ DSM-II diagnoses with their responses to a 100-item symptom checklist administered by a psychiatrist. They found that the distribution of symptoms generally did ‘not conform to patterns postulated in the official classification system’ since they were ‘distributed across the whole range of disorders in mixed patterns’ (Thorne and Nathan, 1969, p. 382). Only ‘functional psychosis’ was clearly differentiated, while the symptoms of ‘psychoneurosis’ were found in all diagnostic categories and ‘personality disorder’ was ‘essentially undifferentiable’ from other categories (Thorne and Nathan, 1969, p. 382). Moreover, some of the supposedly classical symptoms of categories were so rare or occurred in such mixed patterns that they had ‘little or no diagnostic predictive power’ (Thorne and Nathan, 1969, p. 382).
However, not only did the DSM categories lack validity, other studies suggested that psychiatrists could not use them reliably. In a joint US–UK study of the psychiatric diagnosis of schizophrenia, Kendell et al. (1971) found that US psychiatrists had a much broader construct of schizophrenia than their UK colleagues, and so were much more likely to diagnose it. Spitzer and Fleiss’s review of studies of diagnostic reliability acknowledged the ‘obvious unreliability of psychiatric diagnosis’ (Spitzer and Fleiss, 1974, p. 344) and argued that reliability could be improved through the use of detailed, specific criteria and structured diagnostic interview schedules.
2.2 Campaigning and diagnosis: the fall of one category and the rise of another
The 1970s saw two different campaigns by activist groups: one that aimed to remove homosexuality from the DSM, and another that aimed to introduce war trauma.
The DSM and homosexuality
Homosexuality had long been regarded as pathological within psychoanalysis and psychiatry, and it had been included as a ‘sexual deviation’ in the personality disorder category in both DSM-I and DSM-II. Many psychologists and behaviour therapists used sexual aversion therapy with gay men, which involved the use of electric shocks (Cromby, Harper and Reavey, 2013). However, the gay rights movement gathered momentum following the 1969 Stonewall riots in New York against homophobic policing, after which lesbian and gay activists disrupted several APA conventions. Kutchins and Kirk (1999) reported that Robert Spitzer, a psychiatrist and professor of psychiatry at Columbia University in New York, met gay psychiatrists and apparently became convinced of the need to change the classification, though he proposed retaining a category for those who were unhappy with their homosexuality. Following further discussions within the APA, in 1973 its board of trustees voted to remove homosexuality from DSM-II but also to introduce a new category of ‘sexual orientation disturbance’ for those unhappy with their sexuality. Attempts by psychoanalysts and other psychiatrists to overturn the decision failed when they lost an APA referendum in 1974. DSM-III relabelled the category as ‘ego-dystonic homosexuality’. Apart from the obvious issue that such ‘disturbances’ of sexuality were only being applied to homosexuals, this category also ignored the impact of widespread prejudice and discrimination. While ‘ego-dystonic homosexuality’ was dropped, the category of ‘sexual disorder not specified’ (including ongoing and significant distress about one's sexual orientation) was included until the publication of DSM-5.
Vietnam veterans, trauma and the DSM
Following the Vietnam war, many campaigners and sympathetic psychiatrists felt that veterans were not being adequately diagnosed or treated for the psychological effects of combat, particularly distress resulting from a war that had been the subject of so much debate in the US. A new diagnostic category would be a means to provide the treatment needed, and to secure this treatment from the Veterans Administration in the US. Once the process to produce DSM-III had begun in 1974, psychiatrists and Vietnam veteran activists lobbied Spitzer (who was leading the effort to develop DSM-III) to introduce a category that might adequately address the needs of these veterans. As a result, Spitzer set up the Committee on Reactive Disorders, and the new category of ‘post-traumatic stress disorder’ (PTSD) was included in DSM-III (Kutchins and Kirk, 1999).
Pause for reflection
Why do you think one group of campaigners sought to de-medicalise homosexuality while another group sought to medicalise trauma resulting from war?
3 DSM-III and DSM-III-R: Spitzer’s revolution
Robert Spitzer appointed a dozen committees which made recommendations about different categories. A key principle was that ‘DSM-III reflects an increased commitment in our field to reliance on data as the basis for understanding mental disorders’ (APA, 1980, p. 1). For Spitzer, detailed descriptive diagnoses were the foundation on which a scientific psychiatry could begin to test out theories of aetiology.
Aetiology A medical term that refers to theories about the causes of disorder or disease.
DSM-III, published in 1980 by the APA (APA, 1980), introduced a number of major changes designed to address problems of reliability:
Category boundaries: DSM-III drew clear boundaries around categories, advising clinicians to make multiple diagnoses if necessary, even within the same category.
Specific diagnostic criteria: For 163 of the 228 categories, specific criteria were included which needed to be satisfied before a diagnosis could be given.
An atheoretical approach: Since the aetiology of many conditions was considered unclear, DSM-III proposed defining categories in descriptive terms that did not imply a particular causal explanation. The term ‘disorder’ was much more frequently used; thus, DSM-II’s ‘neuroses’ were now labelled as ‘affective disorders’ (including depression) and ‘anxiety disorders’.
A multi-axial system: In order to provide a full, detailed assessment, different kinds of information needed to be gathered, and these were conceptualised along five different axes.
Field trials: A series of field trials were conducted to provide feedback on the new criteria and to assess whether they led to increased reliability.
The multi-axial system was a marked diversion from DSM-II. Diagnoses of mental disorders were made using the first two axes: Axis II included ‘personality disorders’ and ‘specific developmental disorders’ (e.g. ‘developmental reading disorder’), while Axis I included all other disorders. This meant that a person could be given a diagnosis on both Axes I and II. Since psychiatric service users could also have ‘physical disorders and conditions’, these were identified on Axis III. The last two axes were intended primarily for researchers: Axis IV enabled the identification of relevant psychosocial stressors, while Axis V provided a rating system to assess the extent to which a person’s problems affected their everyday adaptive functioning.
There has been debate about whether DSM-III was really atheoretical. For example, including PTSD, a category clearly based on a causal theory (i.e. that distress is the result of traumatic events), seems contrary to this aim. Moreover, the kinds of symptoms included in DSM-III tended to be those more consistent with biological models (Frances, 2013). Indeed, some categories were labelled as ‘organic’, implying a biological cause. The group of psychiatrists supporting Spitzer’s approach certainly advocated a medical model, although they did not seem to think this was a theoretical approach or that it involved presuppositions: ‘the medical model is without a priori theory but does consider brain mechanisms to be a priority’ (Compton and Guze,